Breathing is currently a buzz word in the rehab, strength and performance settings. Recently physical therapists, chiropractors, personal trainers and strength coaches have been discussing breathing and how it relates to core stabilization and shoulder, neck, back and hip pain. In a rehab setting Hodges et al (2002) observed that the diaphragm contributes to spinal stability by adding to intra-abdominal pressure and enhanced spinal stiffness. In a performance setting breathing and "bracing" properly can help to increase strength and promote improved recovery through promoting a return to a relaxed state after a hard workout.

I am not the first person nor will I be the last to discuss breathing and how it relates to posture, hip, back and shoulder pain, core stability and athletic performance. Though I may be the first person to bring it to your attention and how it may be affecting your pain and recovery.

Contrary to popular belief your lungs are not your primary vessel of inhalation. Instead it is your diaphragm that should drive inhalation as it "acts like a pump at the base of the lungs" (Calais-Germain, 2006). If you watch this video you will see the 4 month old breathing diaphragmatically, eliciting a proper overall expansion of its belly to the front, sides, and back. This is what a proper diaphragmatic breathing pattern looks like.

The central nervous system drives this breathing pattern as it drives all other bodily functions. Nowhere during development did someone teach the baby to breath this way, it intuitively knew that in order to survive, this is how it needed to breathe. When the baby breathes this way his diaphragm is contracting and relaxing properly and by doing so he is able to promote the proper exchange of gases in a passive manner, not even thinking about each breath that he takes. This diaphragmatic breathing then serves as the baby's basis for trunk stability as they will create inter-abdominal pressure between their diaphragm and pelvic floor prior to reaching outside of their base of support, learning to crawl and squat. If you have experience in watching a baby work their way up to walking you will find that they do so as they learn how to properly and reflexively stabilize their trunk in each developmental position. You never see a baby holding their breathing while moving, lifting or carrying. I would contest that you shouldn't be doing this either except for specific occasions in a healthy population.

If you watch a baby move, you will not see an increase in the baby's lower back curve. Instead you will see a cylindrical expansion of the belly to promote core stability and a neutral or flat lumbar spine (low back). This is not always the case in an adolescent or adult.

As people age whether it be daily central nervous system stressors or postural habits somewhere along the line most of us lose the ability to properly breathe with our diaphragm. Take a look at your spouse or child and be more aware of how you, yourself is breathing. Do you see their chest rise and neck muscles turn on? Are they/you using their chest and neck muscles to drive their breathing pattern, or do you see their belly cylindrically expand?

Breathing apically, or with upper chest and neck musculature, can lead to many physiological and structural changes that can negatively influence a person's spinal column, pelvic positioning and soft tissue attachments. This may lead to neck, shoulder and chest tightness causing headaches, shoulder problems and back pain.

When your neck, low back, or shoulders are out of position or alignment due to increased soft tissue restriction, weakness, increased low back curve, increased anterior pelvic tilt or elevated rib position, injuries occur due to a weak link in the kinetic chain. For instance in a patient with an elevated rib position their shoulder blade will not sit in an optimal, mechanically advantageous position which may lead to problems after repetitive throwing or lifting overhead activities. When a patient has an increased anterior pelvic tilt or increased low back curve this may lead to low back pain or hip problems.

When looking further into the diaphragm it serves two functions. Postural and respiratory. When the diaphragm trends more toward abnormal stabilizing function it has been shown to lead to low back pain. In a study performed by Kolar, et al (2012) they examined the function of the diaphragm during postural limb activities in patients with chronic low back pain comparing them to healthy controls. What they found was that patients with chronic low back pain appeared to have both abnormal position and a steeper slope (indicating increased postural tone and lessened respiratory function) of the diaphragm, which may contribute to the etiology of the low back pain.

Both Radebold et al (2001) and O'Sullivan and Beales (2007) also found that patients with low back pain also tend to have poor core muscle activation and brace their superficial abdominal muscles and diaphragm. This bracing of the diaphragm limits is respiratory function and limits its ability to create intra-abdominal pressure which most clinicians and trainers should agree that this is ideal for core stability. This negative influence on normal diaphragm function which inhibits diaphragmatic breathing and encourages an upper chest or apical breathing pattern can lead to neck pain, headaches, shoulder or low back pain.

Finally Mehling (2005) examined the effect of breath therapy on patients suffering from chronic low back pain. In testing both pre- and post-intervention measures he found that breath therapy alone provided a safe and effective alternative treatment to help those who have suffered from chronic low back pain.

As you see everything is connected and not all pathologies originate at the point of pain and how you breathe may be the fundamental basis of recovery that is often overlooked. Through several different mechanisms dysfunctional respiratory functional may be an underlying cause to your presenting symptoms and should be examined by a knowledgeable healthcare professional. By no means are proper diaphragmatic breathing patterns the end all be all but it is certainly an often overlooked component to the treatment plan of care and subsequent rehabilitation.


Calais-Germain, B. (2006) Anatomy of Breathing. Seattle, WA:  Eastland Press.

Hodges PW, Gurfinkel VS, Brumagne S et al 2002 Coexistence of stability and mobility in postural control: evidence from postural compensation for respiration. Exp Brain Res 144:293–302.

Kolar P, Sulc J, Kyncl M, Sanda J, Cakrt O, Andel R, Kumagai K, Kobesova A. Postural function of the diaphragm in persons with and without chronic low back pain. J Orthop Sports Phys Ther. 2012 Apr;42(4):352-62.

Mehling W,  et al. Randomized,  controlled trial of breath therapy for patients with chronic low-back pain. Altern Ther Health Med. 2005;11:44-52

O'Sullivan P Beale D  2007 Changes in pelvic floor and diaphragm kinematics and respiratory patterns in subjects with sacroiliac joint pain following a motor learning intervention Manual Therapy 12:209–218

Radebold  A Cholewicki J  Polzhofer B  et al 2001., Impaired Postural control of the lumbar spine is associated with delayed muscle response times in patients with chronic idiopathic low back pain. Spine 26(7):724–730

Jon Herting, PT, DPT, CSCS, USAW is a physical therapist and strength coach in Garnet Valley, PA who specializes in athletic rehab, reconditioning and return to sport.  He is a guest contributor for Sports Doc.

Read more Sports Doc for Sports Medicine and Fitness.